Regular readers are aware that I have devoted little attention to the healthcare reform debate in my daily columns. My hesitation to engage directly on this topic stems from the enormous complexity of the issues involved and the massive attention that this topic has received since January 2009. As the debate reaches its critical phase, as Washington’s politicians ready themselves for some definitive closure, and contemplate alternative courses of action, I have decided to share with you some insights that should – but that almost certainly will not – influence the final decisions.
1. All human beings ultimately will die: No one is immortal, whatever the medical care available. So even if a society decided to allocate its entire resources to death prevention, death would still occur. More important, because the marginal cost of death protection increases dramatically as an individual draws near to that occurrence – in the United States on average one-third of an individual’s lifetime medical costs are incurred in the final year of life – there are enormously diminishing returns to life-protection. In this sense, death juries are inevitable. Decisions to cut off or to cut back on life protection are made all the time by patients, as well as by doctors, insurance companies, and families. The United States already expends more of its resources per capita on health care than any other nation on the planet. And the outcome is not spectacular, at least in terms of death prevention, though it is markedly better in terms of the quality of lives that continue to be lived. Almost certainly, it expends more than individuals themselves would outlay in a free market in health care, where they would have to confront directly the cost upon their families of hopelessly trying to extend their lives.
2. Health care is not just a matter of medicine and treatment: The good health of an individual is a function, to a considerable degree, of genetic makeup and of personal lifestyle choices. The genetic quality of individuals in society is influenced by evolutionary factors. In a system where survival of the fittest rules prevail, those who survive tend to be the fittest, and medical interventions tend to be less necessary, at least until the end. In a system where medical interventions are common-place, the average genetic quality of the survivors will be lower, and medical interventions will appear to be more necessary. I stress that this is an observation, and not a policy recommendation. I am not competent to engage in making medical policy recommendations. Unlike many others, I am well aware of my limitations in this regard. Personal lifestyle choices, however, are under the direct control of each individual. Decisions to live well, to avoid obesity, to eat well, to avoid an excessive use of stimulants and depressants, to rest and sleep well, to exercise appropriately, and to avoid high-risk activities in general, are way more important than medicines and treatments in improving the quality and duration of one’s life. Sadly, the more that medicines and treatments are made available, the less personal care an individual will take of his own health. This is a problem of moral hazard that tends to be downplayed in the health care reform debate.
3. Individual freedom is worth protecting: As I have explained in these columns, I place the highest value on individual liberty, defined as the absence of coercion by one individual over another. Whenever I read, in the current health care reform debate, about the desire of some individuals to impose their will on others, I cringe. Unfortunately, I have grown to cringe a great deal over the past 12 months as suggestions for various kinds of federal oversight over health care provisions have poured out from the mouths and pens of frustrated would-be dictators. The rush to regulate is especially worrying in this debate, not because it is more prevalent than elsewhere, but because it affects one-sixth of the United States economy. If the liberal progressives have their way on this issue, Americans will find themselves far less free 10-20 years from now, than they have ever been, including colonial times. Worse still, they will find themselves irreversibly enslaved, because they will have rendered themselves dependent on the federal government, a government that will have translated itself from representative of their wishes to dictatorial about their needs. The liberal progressives are well aware of this irreversible shift, as is President Obama, whose primary goal appears to be to shift the United States economy from laissez-faire capitalism to state capitalism and, ultimately to socialism.
4. The willingness and ability to pay principle is relevant to health care decisions: In most areas of economic activity, Americans prize their free enterprise system. They recognize that individuals will be differentially rewarded in such a system, as a result of genetic advantage, level and quality of education, choice of occupation, hard work, and sheer good luck or misfortune. They are compassionate towards those who do less well, as long as they are striving to improve their lot. They are a lot less sympathetic to the undeserving poor, those who have brought poverty upon themselves, and who are disinclined to make the effort to retrieve their fortunes. Although medicines and treatments are viewed a little differently – few individuals would wish to see those without resources left bereft of interventions - most Americans reject the notion that access to medicine and treatments should be equal across society. Just as in other areas of activity individuals with greater wealth have better access to resources, so it should be with respect to the market in health care. Otherwise, the incentive to do well will be severely diminished, and the society as a whole will be relatively impoverished. This issue is downplayed in the health care reform debate because of considerations of political correctness that tend to foreclose on open discussion.
Well, these are thoughts enough for one day. Others will follow in tomorrow’s column. The thoughts that I offer to you may well not change your judgment on the current debate. Surely they will not change the policy outcomes. But I hope that they may provide a shade of difference to your reflections on this very important policy issue.